‘Psychopathia Sexualis’

Psychopathia Sexualis is the title of Richard von Krafft-Ebing's text-book of sexual psycho pathology, first published in German in i886. Although there had been many books on erotology since the time of Ovid, Psychopathia Sexualis was the first orthodox medical text-book on psychosexual disorders in man. The nature of the subject matter made the book an imme diate popular success, and it subsequently ran into twelve editions. This success prejudiced the scientific recognition of the book by the medical profession, although no more praise worthy motive could exist for publication of the book than that cited by Krafft-Ebing in his introduction to the first edition: â€ ̃¿ The object of this treatise is to record the various psychopathological manifestations of sexual life in man and to trace how they are conditioned by regular laws.' Krafft-Ebing was born in 1840 in Mannheim into a legal family. This in itself was a major factor in influencing him to write Psychopathia Sexualis in an attempt to combat the ignorance and prejudice about sexual crime which he came to know daily in judicial pronouncements by members of his family. By his early thirties, Krafft-Ebing had the reputation of being one of the best neuropsychiatrists in central Europe. His careful clinical observations were recorded in his Lehrbuch der Psychiatrie, whilst his status as a psychiatrist and neurologist was to be finally recognized by his promotion from the Chair of Neurology and Psychiatry at Strasbourg to succeed Professor Meinert in Vienna. This post he was to hold from 1889 until his death in 1902 at the age of 62. In general psychiatry, Krafft-Ebing is best known for his research in establishing the connection between general paralysis of the

on psychosexual disorders in man. The nature of the subject matter made the book an imme diate popular success, and it subsequently ran into twelve editions. This success prejudiced the scientific recognition of the book by the medical profession, although no more praise worthy motive could exist for publication of the book than that cited by Krafft-Ebing in his introduction to the first edition: â€˜¿ The object of this treatise is to record the various psychopathological manifestations of sexual life in man and to trace how they are conditioned by regular laws.' Krafft-Ebing was  was to be Wagner-Jauregg who for his discovery of the malarial treatment of general paralysis of the insane received the one and only Nobel Prize that psychiatry has ever claimed.
Psychopathia Sexualis was intended as a text book for the doctor and the jurist. Nevertheless, the fact that it ran into ten editions in @almostas many years suggests that it must have been read by many others. The point was not lost on reviewers in this country. today, though some broad generalities may still hold true.' I would suggest that Psychopathia Sexualis has been a much maligned and neglected medical text-book, largely through the notoriety its publication attracted.
Written with a truly scientific purpose, based upon restrained inter pretation, this work still has important contribu tions to make, particularly in influencing the direction of clinical research in the field of sexual psychopathology.
Historians, I am sure, will acclaim Krafft-Ebing as the founder of modern sexual psychopathology who set the scene for Freud and Havelock Ellis.
In a characteristic Teutonic manner, Krafft Ebing first devoted himself to the classification of sexual disorders. He made distinction between perversionâ€"a disease, or â€˜¿ paraesthesia' and acts resulting from vice or depravity, which he called â€˜¿ perversity'.He emphasized that differ entiation must depend on investigation of the whole personality of the individual. Perversion corresponded with the definition quoted by Scott (1964), that it is â€˜¿ any deviation from normal heterosexual coitus which is fixed and exclusive '. Freud (1905)  Krafft-Ebing, like so many psychiatrists of his period, was trained in both neurology and psychiatry. This is soon evident in the book, not only because of his recognition that sexual perversions were frequently associated with brain damage (Kolarsky et al., 1967)  and hypersexuality (Pilleri, 1966). Refinements of these experiments demonstrated that a lesion in the ventromedial nucleus of the hypo thalamus could inhibit the perverse sexual behaviour ofadult monkeys after amygdaloidec tomy, and it is now becoming generally accepted that the limbic system is closely related to sexual responsiveness in man, and that destructive lesions in this system can lead to anomalous sexual behaviour (Kolarsky et al., 1967).
Although the effects of castration upon sex organs and sexual behaviour have been known since Biblical times, it was the experiments of the German physiologist Berthold in 1849 on the implantation of testes into capons that opened the modern era of sexual endocrinology. sought for these procedures on the basis of rather superficial follow-up studies. Psychoanalysis and learning theory cannot explain transsexualism on the basis of learning experience alone, and have to fall back on the supposition of some abnormal psychosexual constitution at birth, probably due to abnormal hormonal or chemical effects upon the brain of the foetus, predisposing it to organize contrary sexual experiences during development (Diamond, 1965).
Krafft-Ebing credited Binet (1887)  participates in some fetishistic practice (Johnson, 1967). Although psychoanalysis has provided deep insights into the symbolic associations of many forms of fetishism, psychoanalytic treat ment of fetishism has been an abysmal failure. Raymond (1956), however, can be credited with making the first break in the stranglehold which psychoanalysis had held for 40 years in this field. He published the case of a 32-year-old married man who had appeared in court charged with abnormal behaviour derived from perambulator and handbag fetishism. Raymond  clothing of the opposite sex, become the pre requisite for sexual arousal when worn by the patient. The condition is a common latent cause of male impotence, and like many forms of fetishism is associated with high incidence of temporal lobe dysrhythmias in the EEG. Although transvestism is more commonly in dulged in as a form of vicarious, incidental sexual excitement by otherwise normal males, i.e. as a sexual deviation, it may in some cases become completely exclusive and attain the severity of a perversion. It is in these cases that treatment by chemical or electrical aversion therapy has such a hopeful place in treatment (Barker, 1965). Krafft-Ebing gave the first clinical description of sadism and masochism, terms which he derived from the writings of de Sade and Sacher-Masoch (Deleuze, 1971). His own case histories demonstrating these disorders vary from the simple biting behaviour of sexual foreplay to the sadistic lust murders ofJack the Ripper and the masochistic perversions of Rousseau and Baudelaire. He was one of the first physicians to describe the autosexual perversion of corset fetishism and what he called â€˜¿ fettering' where the individual becomes sexually aroused when bound in tight clothing with straps or ropes. Although cases of exclusive sado-masochism are rare and are largely seen by forensic psychiatrists, gratification of masochistic phantasies is fre quently met in the anamnesis of rape in female hysterical patients, whilst the phantasies of many impotent males and of pornographic literature often have a strong sadistic content.
Krafft-Ebing conceptualized sado-masochism as a pathological intensification of the normal emotional concomitants of the sexual act, due to a psychopathic constitution. Freud, in his essay â€˜¿ A child is being beaten' in 1919, put a more dynamic interpretation of sado-masochism; he explained the content of these perversions as substitutive gratification for wishing to be beaten oneself in order to atone for erotic desires for incestuous relationships with the mother. This was the basis ofhis famous aphorism â€˜¿ perversions are the negative of neuroses', for in this parti cular perversion he saw pure Oedipal conflict emerging with a minimum of displacement and disguise. Witnessing coitus between parents was thought to sexually stimulate the child with sadistic phantasies through identification with the father imagined as engaging in sadistic assault upon the mother.
Whilst these psychoanalytic speculations con tribute to understanding the content of abnormal sexual behaviour they do not help in explaining their form. Sadism in the female, as Krafft Ebing rightly said, is contrary to the female constitution, and the rare cases he recorded, such as vampireism, were psychotic. Although the Freudians added much to understanding the content of sado-masochistic behaviour, they could offer little to explain its form or why it developed to a pathological intensity in certain individuals. Nor can it be said that there has been any real progress in this subject since Krafft-Ebing's original writings, and our ignor ance of the interplay between pain and sexuality remains a reproach to forensic psychiatry.
Exhibitionism cyproterone, which early trials suggest is ex tremely useful in the controlling of hypersexual deviants (Petri, 1969). Krafft-Ebing, like most of his contemporaries, thought that the sexual perversions, neurasthenia and psychosis were all the result of degenerative changes in the brain secondary to sexual excesses, particularly mas turbation, whilst other forms of neurosis were sometimes attributed to sexual abstinence. This theory of pathogenesis was at that time as ubiquitous in its application as the castration complex was to become in psychoanalysis. The role of masturbation in the causation of sexual perversions is once again, however, coming under scrutiny. Masturbatory phantasies in early childhood are likely to be repeated and the associated phantasy firmly imprinted.
If, in addition, the individual's abnormal per sonality traits restrict his social contacts, then these early and often abnormal sexual stimuli will persist and through reinforcement will prevent the development of more mature patterns of sexual behaviour.
An immature pattern of sexual gratification will thus persist, as Freud suggested, and will become fixed and exclude normal sexual activity. This has become the central theme of the theory of sexual devia tion advanced by McGuire ci al. (1965). This emphasizes that repetitive masturbatory deviant phantasy is the main mechanism whereby abnormal conditioned sexual responses are made. To support their theory they point out that masturbation in the immature as well as the mature female is much less common than in the male (factually confirmed by Kinsey) and from this they argue that therein lies one explanation of why sexual perversion and deviation are less common in the female than in the male. It is thus interesting to see how modern learning theory places great emphasis upon the aetiological role of masturbation in sexual perversion, as did Krafft-Ebing. Like him, the learning theorists advise their patients not only to abstain from their deviant practices but deliberately to avoid masturbation and thus provide an opportunity for extinction of the abnormally conditioned sexual response through hypnosis or by applying aversive stimuli.
The largest section of Psychopathia Sexualis is devoted to those whom Krafft-Ebing chose to call â€˜¿ Nature's stepchildren', afflicted with the inverted sexual drive, or sexual inverts. Although he credits Caspers with the first complete clinical descriptions of homosexuality, many references to it had previously been made in medical literature. Morison (1843) referred to homo sexuality as a â€˜¿ monomania with unnatural propensity', and went on to say â€˜¿ it is a consola tion to know that it is sometimes the conse quence of insanity . . . I have met with ten cases at least in which it was the effect of cerebral disease'. This was to contrast with the religious doctrine that homosexuality was always a vice and was acquired. Havelock Ellis (1900), in his extensive review of sexual inversion, gives historical biographies of such famous homo sexuals as Francis Bacon, Oscar Wilde, Walt Whitman, Marlowe, Michelangelo and Leo nardo. Griesinger (quoted by Krafl't-Ebing, 1893) was, however, the first to emphasize that heredity played the major part in the causation of homosexuality, and it was not always a vice.
This was supported by the repeated findings that in whatever population the incidence of complete homosexuality was studied, the figure of 4 per cent recurred. Little more was contri buted of significance until Kallmann (1952), in a study parallel to that in schizophrenia, reported that there was an i oo per cent con cordance for homosexuality in monozygotic twins and only 12 per cent for dizygotic twins.
These figures have since been doubted, and to some extent retracted even by Kallmann. Heston and Shields ( I 968) gave a comprehensive review of this whole problem and themselves reported a unique family of 14 siblings con taming three pairs of monozygotic twins. In two pairs both twins were homosexuals, whilst in the third pair both twins were heterosexual. Slater (1962), however, demonstrated the tendency of homosexuals to be born late in sibships and to older mothers than comparable groups of heterosexuals. He drew a parallel with mongolism, and inferred a possibly similar genetic mechanism. Alternatively, a genetically susceptible child born to elderly parents may be more vulnerable to the intense emotional rela tionships with the parent of the opposite sex. Psychoanalysis shifted the aetiological emphasis away from heredity towards viewing homo sexuality as a sequela of â€˜¿ castrationanxiety', determined by the effect of experience upon a basic sexuality which was to choose in which direction it moved. Whilst male homosexuals selected from clinic and forensic sources do exhibit a high frequency of intense emotional relationships with their mothers, when this observation is extended to adjusted homosexuals at large this feature subsides (Schofield, 1965). Clearly one has to invoke a constitutional factor in addition to the experiential one emphasized by the dynamic psychologists.
Krafft-Ebing considered what today we should call homosexuality as one step along the con tinuum to a psychophysical constitution identical with the opposite sex. He recognized congenital and acquired forms and for each four different varieties. He went on to make many enlightened suggestions regarding alterations in the law, which would reduce the incidence of social and neurotic reactions in the homosexual. In this country these views have been met only in recent years through legislative changes (Sexual Offences Act, 1967). Claims to be able to con vert homosexual to heterosexual behaviour have always been made enthusiastically by psycho analysts (Rosen, 1968 (Rosen, 1968). No clinician can afford to ignore the impressive claims made by behaviour therapy in treating the homosexual motivated for change, and it would seem obligatory upon any psychiatric clinic to be able to offer this form of treatment. Krafft-Ebing confined his treatment of paedo philia to the section of the book devoted to forensic topics. In his view, paedophilic acts were committed either by young men who lack courage or have no faith in their virility or by rouÃ©'s who have to some extent lost their power, or by persons suffering from gross brain disease; but there were also individuals with a morbid psycho-sexual perversion in that direc tion. It was the psychoanalysts who realized the widespread nature of this disorder in its milder forms and viewed it as a phobia of pubic hairâ€"the latter arousing castration anxiety in the subject.
In their factual study of paedophilia, Mohr and Turner (1964) empha sized that in heterosexual paedophilia the young victim is seldom a complete stranger to the offender, and in many circumstances, such as incest, is often the active seducer. The act itselfis invariably one ofimmature gratification, whilst physical assault or an attempt at inter course is rare. Homicidal paedophilia is un common, according to these authors, and when a murder does result it is not the direct sexual aim of the offender but usually happens as a panic measure to prevent discovery. Homo sexual paedophilia is a different clinical problem. Apart from its involving pubertal children, the rate of recidivism is high, approaching that of the exhibitionist, and requires stringent methods of management.

Three main factors emerge from Psychopathia
Sexualis as important in the causation of sexual pathology in man. The abnormal sexual anlage, so much favoured by Krafft-Ebing as underlying sexual perversion, has been revealed over the past go years since Psychopathia Sexualis was written as a complex neuro-endocrine diathesis.